Part B Insider - 2009 Issue 1
Reader Question: Don't Undercode Condition Checks
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Article Overview
This reader question reviews how to think about evaluation and management coding when patients present for follow-up of multiple chronic problems. It discusses documentation of history elements, examination breadth, and medical decision-making at a general level so clinicians and coders can better judge whether a higher-level office visit may be supported. The article is aimed at those coding office E/M encounters and reviewing how chronic conditions are reflected in the record.
Why This Topic Matters
Follow-up visits with several ongoing conditions are common, and incomplete documentation can make the encounter appear less complex than it really is. Understanding the overall documentation framework helps support accurate E/M leveling and reduce the risk of undercoding.
What You Will Learn
- How chronic-condition follow-up visits can affect office visit level determination
- How history, exam, and medical decision-making are considered together in an E/M encounter
- How documentation of ongoing problem status is reflected in the record
- How general E/M framework concepts apply to established patient office visits
Who Should Read This
- Medical coders
- Coding auditors
- Physician documentation specialists
- Clinicians documenting office visits
Codes Discussed
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